Knowledge Area 15 | Urogynaecology & Pelvic Floor Problems
(Aligned with RCOG Core Curriculum 2019)
Many MRCOG candidates find urogynaecology intimidating. In reality, this is a focused and highly structured module. It becomes straightforward once you understand three pillars:
1. Pelvic floor anatomy and pathophysiology
2. Urodynamics and its interpretation
3. Stepwise, patient-centred management
According to the RCOG curriculum, trainees are expected not only to understand management but also to demonstrate safe practice, shared decision-making, and awareness of governance issues. This is where many candidates struggle to score marks.
What the Curriculum Expects You to Know
Pelvic Organ Prolapse (POP)
You must understand:
- Pelvic floor anatomy (muscles, fascia, nerve supply)
- Risk factors: parity, advancing age, obesity, chronic cough, constipation
- POP-Q classification system
- Conservative management
- Surgical options
- Complications and recurrence risk
- Consent and mesh-related governance
Management Approach
First-line: Pelvic floor muscle training; Vaginal pessary
Surgical options (if indicated): Vaginal hysterectomy with repair; Anterior/posterior colporrhaphy; Sacrocolpopexy; Native tissue repair (preferred in most cases)
Mesh use is now highly regulated in the UK. Following national review and safety concerns, restrictions were introduced by NHS England with guidance supported by the UK Continence Society.
For exam purposes, focus on: Informed consent, Risks of chronic pain, erosion, dyspareunia, Alternative options, Documentation
Urinary Incontinence
You must differentiate clearly between:
Stress Urinary Incontinence (SUI): Leakage on effort, exertion, coughing, sneezing.
Management: Pelvic floor physiotherapy (minimum 3 months); Surgical options if conservative treatment fails:
Mid-urethral sling (under strict governance)
Colposuspension
Autologous fascial sling
Detrusor Overactivity (Overactive Bladder): Urgency, frequency, nocturia ± urge incontinence.
Management: Bladder training, Antimuscarinic agents, Beta-3 agonists (e.g. mirabegron), Intravesical botulinum toxin (selected cases), Neuromodulation (refractory cases)
Mixed Urinary Incontinence
Management depends on: Predominant symptom AND Urodynamic confirmation
This is frequently tested in SBA and clinical scenarios.
Urodynamics – A Scoring Area in Exams
You must be able to interpret: Filling cystometry, Detrusor overactivity traces, Stress leakage on cough, Pressure-flow studies
Managing urogynecological issues solely on the basis of symptoms is a common exam trap. Correct management must correlate with urodynamic findings.
Quality of Life & Multidisciplinary Approach
Pelvic floor disorders significantly impact: Sexual function, Body image, Mental health, Social participation
MDT may include:
Urogynaecologist; Pelvic floor physiotherapist; Continence nurse specialist; Colorectal surgeon; Psychologist (if required)
RCOG curriculum strongly emphasises: Use of patient-reported outcome measures, Shared decision-making, Multidisciplinary team involvement
Overall there is now:
- Greater emphasis on conservative-first management
- Stricter regulation of vaginal mesh surgery
- Centralisation of complex mesh procedures
- Strong focus on consent and documentation
- Governance awareness in clinical decision-making
How to Organise Your Revision
Create one master folder: Urogynaecology & Pelvic Floor Disorders
Subfolders:
- General Topics
- Urinary Incontinence (SUI / OAB / Mixed)
- Pelvic Organ Prolapse
- Urodynamics & Investigations
- Bladder Pain Syndrome
- Consent, Governance & Mesh
This structured approach prevents overwhelm and improves retention.
To score well:
- Understand physiology
- Interpret investigations correctly
- Apply stepwise management
- Discuss consent thoroughly
- Address quality of life
If you approach it systematically, Urogynaecology becomes a scoring topic rather than a feared one.
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General Topics |
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NICE |
NG #123 Urinary incontinence and pelvic organ prolapse in women: management April 2019 |
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TOG |
Urethral Caruncles 2024 Management of Urogynae Problems in Pregnancy and Postpartum 2022 Clinical Application of Transperineal USG in Urogynaecology 2022 Pelvic Floor Functional Bowel Disorders 2020 Laparoscopy in urogynaecology 2018 Fowler’s syndrome 2018 Cystoscopy for the gynaecologist: how to do a cyctsoscopy 2017 Urethral diverticulum 2015 Recurrent UTI 2020 Catheter use in gynaecological practice 2014 The management of urogynaecological problems in pregnancy and the early postpartum period 2012 UTI in Pregnancy 2008 |
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Pelvic Organ prolapse |
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GTG |
#46 Post-Hysterectomy Vaginal Vault Prolapse |
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TOG |
Management of uterine prolapse: is hysterectomy necessary? 2016 Continence Surgery at the time of POP repair 2019 Vaginal mesh in prolapse surgery 2018 Management of Vault prolapse 2013 |
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RCOG |
Consent Advice 5 – Vaginal Surgery for prolapse |
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Urinary Incontinence |
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SIP |
#42 Botulinum Toxin for an Overactive Bladder |
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TOG |
Non-mesh surgery for stress urinary incontinence 2021 Use of urethral bulking agents in SUI 2020 Interpretation of urodynamics studies 2019 The conservative (non-pharmacological) management of female urinary incontinence 2014 Management of refractory overactive bladder 2016 |
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Bladder Pain Syndrome |
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GTG |
#70 Management of Bladder Pain Syndrome |
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TOG |
Advances in Bladder Pain Syndrome 2022 |